Reports to the Manager of Appeals and Denials. Ensures that charging/coding/billing is compliant with regulatory guidelines and optimizes reimbursement from third parties. Manages and tracks denials from third parties and initiates action for denial resolution, appeal and prevention. Provides proactive assessments of potential or actual contractual or legislative changes to reimbursement.
MISSION & VISION
To enhance the physical, mental and emotional well-being of the communities we serve as the community’s provider of outstanding quality, superior value and comprehensive health care services.
Our vision is to achieve:
Education and Experience
- Innovative health care and well-being services of the highest quality at the greatest value
- Easy access and convenience
- Outstanding patient experiences
- Ongoing education involving physicians, patients and the community
The knowledge, skills and abilities as indicated below are normally acquired through the successful completion of a post-secondary degree in Health Information Management, Nursing, Medical Billing or other related field. A minimum of three years of related experience in the healthcare field involving reimbursement, coding, appeals and/or billing processes.
Knowledge & Skills
- Requires fundamental knowledge of the revenue cycle process, which includes such things as patient access, utilization review, charge capture, HIM and patient accounting.
- Requires the advanced analytical and critical thinking skills necessary to audit patient care data, associated patient care documentation and identify variances in standards of care.
- Requires knowledge of rules and regulations pertaining to hospital reimbursement.
- Requires familiarity with managed care principles and an understanding of post-acute continuum of care.
- Requires the interpersonal skills necessary to maintain effective working relationships and interact effectively with staff, physicians, review agencies, insurance companies, patients and patients’ families.
- Requires the effective communication skills (both verbal and written) necessary to prepare documentation, write appeal letters and to provide education to staff and physicians regarding the revenue cycle process.
- Demonstrates the ability to be self-motivated, detail oriented and make independent decisions. Also demonstrates the ability to respond quickly and appropriately to customer requests.
- Demonstrates a working knowledge of the Hospital’s computer systems (e.g., Star McKesson, Cerner Power Chart, PIC and Cobius) and proficiency in basic computer skills (i.e., data entry, word processing, spreadsheets, utilizing the internet, etc.).
1. Works in a professional office environment.
2. May experience some mental/visual fatigue due to the frequent and close work with detail and computers.
3. Work may require travel between Beacon facilities.
Requires the physical ability and stamina to perform the essential functions of the position.
ESSENTIAL JOB DUTIES
The below statements are intended to describe the essential job functions and level of work performed by individuals assigned to this classification. They are not to be construed as an exhaustive list of all job duties performed by the personnel occupying this position.
1. Revenue Recovery/Denial Prevention:
- Manage and track denials from third parties and initiate action for denial resolution, appeal and prevention.
- Analyze and resolve problems that affect the claim submission process.
- Involved in other revenue recovery initiatives.
- Maintains denial databases.
- Timely and accurate reporting of denials to Administration and departments.
- Monitors the Medical Necessity checking process performed in the hospitals. Also is responsible for addressing Medical Necessity issues
- that arise with department and physician.
- Utilize and assist in daily maintenance of the Payment Integrity Compass product which is used by the Revenue Cycle departments.
2. Regulatory Changes and Compliance:
- Review regulatory documentation to ensure current charging/coding/billing is compliant with guidelines and to optimize Hospital reimbursement from third parties.
- Work with departments/physician practices in analyzing and adjusting operations related to new regulations impacting their area.
- Disseminate regulatory information to departments that pertains to payment for their services.
3. External Audits and Special Projects:
- Complete projects related to: denials, reimbursement, billing and charge capture.
- Work with departments on recovery or appeal effort as it relates to external audits and recoupment by governmental or managed care payors.
4. Performs other functions to maintain personal competence and contribute to the overall effectiveness of the department:
STANDARDS OF BEHAVIOR
- Completes other job-related assignments and special projects as directed.
Anticipates and takes proactive steps to ensure customer’s needs are met
Places courtesy and service above routine and goes beyond customer expectations
Keeps patient/work environment neat and clean
Understands and applies job-related aspects of patient safety and identifies, reports and corrects safety concerns as quickly as possible
Keeps others well informed
Practices active listening
Develops and maintains positive working relationships
Uses problem solving techniques to resolve issues and makes decisions within personal sphere of influence
Seeks to understand patient's experience
Demonstrates integrity and strong business ethics
Utilizes time and resources in a prudent manner
Strives to continually improve department processes and services
Projects professional image through enthusiasm towards work, behavior and appearance
Demonstrates Beacon values verbally and through actions
Displays and exhibits caring behaviors with each interaction
Demonstrates self-awareness and sensitivity to the perceptions of others
Listens carefully to input and concerns and takes appropriate action
Interacts with dissatisfied customers in a calm, respectful manner and seeks resolutions
Maintains confidentiality at all times
Fosters a sense of trust and collaboration among associates
Verbal and written communications are clear and effective
Responds to change in a positive manner
Associate complies with the following organizational requirements:
Commitment to Beacon's six-point Operating System, referred to as The Beacon Way:
- Attends and participates in department meetings and is accountable for all information shared.
- Completes mandatory education, annual competencies and department specific education within established timeframes.
- Completes annual employee health requirements within established timeframes.
- Maintains license/certification, registration in good standing throughout fiscal year.
- Direct patient care providers are required to maintain current BC LS (C PR) and other certifications as required by position/department.
- Consistently utilizes appropriate universal precautions, protective equipment, and ergonomic techniques to protect patient and self.
- Adheres to regulatory agency requirements, survey process and compliance.
- Complies with established organization and department policies.
- Available to work overtime in addition to working additional or other shifts and schedules when required.
- Leverage innovation everywhere.
- Cultivate human talent.
- Embrace performance improvement.
- Build greatness through accountability.
- Use information to improve and advance.
- Communicate clearly and continuously.